NUR 141 SKILL 22-5 ADMINISTERING MEDICATIONS BY INTRAVENOUS BOLUS

INTRODUCTIONIn the past nurses often mixed medications into large volumes of

intravenous (IV) fluids (500 to1000 mL). However today’s safety standards and evidence-based practice no longer support this practice on a routine basis.

Many patient safety risks such as incorrect calculation, poor aseptic technique, incorrect labeling, pump programming errors, lack of medication knowledge, and mix-up with another medication occur when nurses have to prepare medications in IV containers on patient care units.

There are a number of current best practices for preparation and administration of IV medication.

An IV bolus is one method of medication administration currently practice on patient care units.

It introduces a concentrated dose of a medication directly into a vein by way of an existing IV access.

INTRODUCTION – CONT’DAn IV bolus or “push” usually requires small volumes of fluid,

which is an advantage for patients who are at risk for fluid overload.

Administering medications by IV bolus is common in emergencies when you need to deliver a fast-acting medication quickly.

Because these medications act quickly, it is essential that you monitor patients closely for adverse reactions.

Agencies have policies and procedures that identify the medications that nurses are allowed to administer by IV push and other IV routes.

These polices are based on the medication, compatibility and availability of staff, and type of monitoring equipment available.

There are advantages and disadvantages to administering IV push medications.

INTRODUCTION – CONT’DADVANTAGES OF THE INTRAVENOUS PUSH METHODThere is rapid onset of medication effects, which is useful in patients experiencing critical or emergent health problems.

Medications can be prepared quickly and given over a shorter time than by Intravenous (IV) Piggyback.

Doses of Short-Acting medications can be titrated based on a patient’s needs and responses to the drug therapy. This is important for infants, children, and older patients.

Method provides a more accurate dose of medication delivered because no medication is left in intravenously.

INTRODUCTION – CONT’DDISADVANTAGES OF THE INTRAVENOUS PUSH METHOD

Not all medications can be delivered by IV push

There is higher risk for infusion reactions; some are mild to severe because the medication action peaks quickly.

When giving medication quickly (e.g., less than 1 minute), there is very little opportunity to stop the injection if an adverse reaction occurs.

Risk for infiltration and phlebitis is increased, especially if a highly concentrated medication, a small peripheral vein, or a short venous access device is used.

Hypersensitivity reaction can cause an immediate or delayed systemic reaction to a medication, requiring supportive measures.

INTRODUCTION – CONT’DThe IV bolus is a dangerous method to administer medications

because it allows no time to correct errors.

Administering an IV push medication too quickly can cause death.

Therefore be very careful in calculating the correct amount of the medication to give.

In addition, a bolus may cause direct irritation to the lining of blood vessels; thus always confirm placement of the IV catheter or needle.

Never give an IV bolus if the insertion site appears edematous or reddened or if the IV fluids do not flow at the ordered rate.

Accidental injection of some medications into tissues surrounding a vein can cause pain, sloughing of tissues, and abscessed.

INTRODUCTION – CONT’DVerify the rate of administration of IV push medication using agency

guidelines or a medication reference manual.

The institute for Safe Medication Practices has identified the following four strategies to reduce harm from Rapid IV push medications:

1. Make sure that information regarding rate of administration of IV push medication is readily available.

2. Use less concentrated solutions whenever possible.3. Avoid using terms in orders such as IV push, IVP, or IV

bolus with medications that should be administered over 1 minute or longer. Use more descriptive terms such as IV over 5 minutes.

4. Consider alternatives such as a syringe pump to administer medications that has a high risk for adverse effects. If this is not an alternative to IV push, have pharmacy dilute the medication and administer in a piggyback.

BEST PRACTICES FOR ADMINISTRATION OF INTRAVENOUS SOLUTIONS AND MEDICATIONS

Use Standardized concentrations and dosages of medication.

Use standardized procedures for ordering, preparing, and administering intravenous (IV) medications.

Administer solutions and medications prepared and dispensed from the pharmacy or as commercially prepared when possible.

Never prepare high-alert medications (e.g., heparin, dopamine, dobutamine, nitroglycerin, potassium, antibiotics, or magnesium) on a patient care unit.

Use standardized infusion concentration of “high-alert” medications.

BEST PRACTICES FOR ADMINISTRATION OF INTRAVENOUS SOLUTIONS AND MEDICATIONS – Cont’dStandardize the storage of IV medications.

Use the mnemonic CATS PRRR to help remember safety checks for administering IV medications: C, compatibilities; A, allergies; T, tubing correct; S, site checked; P, pump safety checked; R, right rate; R, release clamps; R, return and reassess the patient.

Use standardized label practices. Bold patient name, generic drug name, and patient-specific dose.

Correctly use technology such as intelligent-infusion devices, bar-code assisted medication administration, and electronic medication administration record.

INTRODUCTION – CONT’DVerify the rate of administration of IV push medication using

agency guidelines or a medication reference manual.Review the amount of medication that a patient will receive

each minute, the recommended concentration, and rate of administration.

For example, if a patient is to receive 6 mL of a medication over 3 minutes, give 2 mL of the IV bolus medication every minute.

Understand the purpose of the medication and any potential adverse reactions related to the rate and route of administration.

Some IV medications can only be given IV push safely when a patient is being continuously monitored for dysrhythmias, blood pressure changes, or other adverse effects.

INTRODUCTION – CONT’D

Therefore you can push some medications only in specific areas within a health care agency (e.g., critical care unit).

Confirm agency guidelines regarding requirements for special monitoring.

IV push medications are given through either an existing continuous IV infusion or an intermittent venous access (commonly called a saline lock).

A saline lock is an IV catheter with a small “well” or a chamber covered by a rubber cap.

INTRODUCTION – CONT’DAn IV catheter can be converted into a lock

by inserting a special rubber-seal injection cap into the end of the catheter (see Chapter 28).

Use of a lock saves time by eliminating constant monitoring of an IV line.

It also offers better mobility, safety, and comfort for patients by eliminating the need for a continues IV line.

After you administer an IV bolus through an intermittent venous access, flush with normal saline solution in order to keep it patent.

ASSESSMENT1. Check accuracy and completeness of each MAR or

computer printout with prescriber’s written medication order. Check patient’s name, medication name and dosage, route of administration, and time of administration. Recopy or reprint any portion of the MAR that is difficult to read.

2. Assess patient’s medical and medication history.3. Review medication reference information for

medication action, purpose, side effects, normal dose, time of peak onset, how slowly to give medication, and nursing implications such as need to dilute medication or administer it through a filter.

Knowledge of medication allows you to give it safely and monitor patient’s response to therapy.

ASSESSMENT – CONT’D4. If you give medication through an existing IV line,

determine compatibility of medication with IV fluids and any additives within IV solutions.

IV medication is not always compatible with IV solution and/or additives, and a new site may need to be initiated.

5. Perform Hand Hygiene. Assess condition of IV needle insertion site for signs of infiltration or phlebitis.

Do not administer medication if site is edematous or inflamed.

6. Assess patency of patient’s existing IV infusion line or saline lock (see Chapter 28).

For medication to reach venous circulation effectively, IV line must be patent, and fluids must infuse easily.

ASSESSMENT – CONT’D7. Check patient’s history of medication allergies:

known allergens and normal allergic response.IV bolus delivers medication rapidly. Allergic

response is immediate.8. Assess patient’s symptoms before initiating

medication therapy.Provides information to evaluate the desired

effects of medication.9. Assess patient’s understanding of purpose of

drug therapy.Poses implication for education.

PLANNING• Expected outcomes following completion of the procedure:

• Patient experiences no medication side effects or adverse reactions• Medication administered safely with

desired therapeutic effects achieved.

• IV site remains intact, without signs of swelling or inflammation or symptoms of tenderness at site.• Medication infuses without complications

to IV site and surrounding tissues.

• Patient explains purpose and side effects of medications• Demonstrates learning.

IMPLEMENTATION1. Prepare medications for one patient at a time using aseptic

technique. Keep all pages of MARs or computer printouts for one patient together or look at only one patient’s electronic MAR at a time. Check label of medication carefully with MAR or computer printout 2 times (see Skill 22-1 and Procedural Guideline 22-1) when preparing medication.

Clinical Decision Point: Some IV medications require dilution before administration. Verify with agency policy or pharmacy. If a small amount of medication is given (e.g., less than 1 mL), dilute medication in small amount (e.g., 5 mL) of normal saline or sterile water so the medication does not collect in the “Dead Spaces” (e.g., Y-Site injection port, IV cap) of the IV delivery system.

2. Take medication (s) to patient at correct time (see agency policy). During administration, apply six rights of medication administration.

IMPLEMENTATION – CONT’D3. Close room curtain or door.4. Identify patient using two identifiers (i.e., name

and birthday or name and account number) according to agency policy. Compare identifiers in MAR / medical record with information on patient’s identification bracelet and/or ask patient to state name.

5. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if they have any allergies.

IMPLEMENTATION – CONT’D6. Discuss purpose of each medication, action, and

possible adverse effects. Allow patient to ask any questions. Explain that you will give medication through existing IV line. Encourage patient to report symptoms of discomfort at IV site.

7. Perform hand hygiene and apply clean gloves.

Clinical Decision Point: Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

IMPLEMENTATION – CONT’D8. IV push (Existing IV line):

A. Select injection port of IV tubing closest to patient. Use needleless injection port.B. Clean injection port with antiseptic swab. Allow to Dry.C. Connect syringe to IV Line: Insert needleless tip of syringe containing drug through

center of port.D. Occlude IV line by pinching tubing just above injection port. Pull back gently on

plunger of syringe to aspirate for blood return.E. Release tubing and inject medication within amount of time recommended by agency

policy, pharmacist or medication reference manual. Use watch to time administration. You can pinch IV line while pushing medication and release it when not pushing medication. Allow IV fluids to infuse when not pushing medication.

Ensures safe medication infusion. Rapid injection of IV drug can be fatal. Allowing IV fluids to infuse while pushing IV drug enables medication to be delivered to patient at prescribed rate.

IMPLEMENTATION – CONT’D• 8. IV Push (Existing IV line): (Cont’d from previous

page):• F. After injecting medication, withdraw syringe and recheck IV fluid

infusion rate.

• G. If IV medication is incompatible with IV fluids, stop IV fluids, clamp IV line, and flush with 10 mL of normal saline or sterile water (see agency policy). Then give IV bolus over appropriate amount of time and flush with another 10 mL of normal saline or sterile water at same rate as medication was administered.

• H. If IV line that is currently hanging is a medication, disconnect it and administer IV push medication as outlined in Step 9. Verify agency policy for stopping IV fluids or continuous IV medications. If unable to stop IV infusion, start new IV site (see Chapter 28) and administer medication using IV push (IV lock) method.

IMPLEMENTATION – CONT’D

• 9. IV Push (IV lock):• A. Prepare Flush solutions according to

agency policy.• 1. Saline flush Method (Preferred method):

Prepare two syringes filled with 2 to 3 mL of normal saline (0.9%). Many agencies do not provide prefilled normal saline syringes for flushing IV lines.• 2. Heparin Flush Method (not

recommended; refer to agency policy).

IMPLEMENTATION – CONT’D• 9. IV Push (IV lock): CONT’D FROM PREVIOUS PAGE:

• B. Administer Medication:• 1. Clean injection port with antiseptic swab.

• 2. Insert needleless tip of syringe with normal saline 0.9% through center of injection port of IV lock.

• 3. Pull back gently on syringe plunger and check for blood return.• Indicates if needle or catheter is in the vein.

• 4. Flush IV site with normal saline by pushing slowly on plunger.

• 5. Remove saline-filled syringe.

IMPLEMENTATION – CONT’D• 9. IV push (IV lock): Administering

Medication – Cont’d from previous page:• 6. Clean injection port with antiseptic swab.

• 7. Insert needleless tip of syringe containing prepared medication through injection port of IV lock.

• 8. Inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration.• Many medication errors are associated with IV pushed

being administered too quickly. Following guidelines for IV push rates promotes patient safety.

• 9. After administering bolus, withdraw medication syringe.• Prevents transmission of microorganisms.

IMPLEMENTATION – CONT’D• 10. Clean injection port with antiseptic swab.

• 11. Flush injection port.• A. Attach syringe with normal saline and

inject flush at same rate that medication was delivered.• Flushing IV line with saline prevents

occlusion of IV access device and ensures that all medication is delivered. Flushing IV site at same rate as medication ensures that any medication remaining within IV needles is delivered at the correct rate.

IMPLEMENTATION – CONT’D10. Dispose of SESIP covered

needles and syringes in puncture and leak-proof container.

11. Stay with patient for several minutes and observe for any allergic reactions.Dyspnea, wheezing, and

circulatory collapse are signs of anaphylactic reaction.

12. Remove clean gloves and perform hand hygiene.

EVALUATION

1. Observe patient closely for adverse reactions during administration and for several minutes thereafter.

IV medication acts rapidly.

2. Observe IV site during injection for sudden swelling and for 48 hours after IV push.

Swelling indicates infiltration into tissues surrounding vein. Signs of infiltration may not occur for 48 hours.

3. Assess patient’s status after giving medication to evaluate effectiveness of the medication.

Some IV bolus medications can cause rapid change in patient’s physiologic status. Some medications require careful monitoring and assessment and possibly future laboratory testing (e.g., vasopressors and anti-arrhythmics require blood pressure and heart rate monitoring, and heparin requires laboratory studies after administration to determine therapeutic levels.).

4. Ask patient to explain purpose and side effects of medicationEvaluates Learning.

UNEXPECTED OUTCOMES1. Patient develops adverse reaction to medication.

Stop delivering medication immediately and follow agency policy or guidelines for appropriate response to allergic reaction (e.g., administration of antihistamine such as diphenhydramine {Benadryl} or epinephrine) and reporting of adverse drug reactions.

Notify patient’s health care provider of adverse effects immediately.Add allergy information to patient’s record.

2. IV medication is incompatible with IV fluids (e.g., IV fluids become clouding in tubing) (see agency policy).

Stop IV fluids and clamp IV line.Flush IV line with 10 mL of 0.9% sodium chloride or sterile water at same rate as

medication was administered.Restart IV fluids with new tubing at prescribed rate.If unable to stop IV infusion, start a new IV site (see Chapter 28) and administer

medication using IV push (IV lock) method.

UNEXPECTED OUTCOMES – CONT’D3. IV site shows symptoms of infiltration or phlebitis

(see Chapter 28).Stop IV infusion immediately or discontinue access device

and restart in another site.Determine how much damage IV medication can produce in

subcutaneous tissue.Provide IV extravasation care (e.g., injection phentolamine

{Regitine} around IV infiltration site) as indicated by agency policy, use a medication reference, and consult pharmacist to determine appropriate follow-up care.

4. Patient is unable to explain medication information.Provide patient with additional information, or patient is

unable to learn at this time.

RECORDING AND REPORTING• Immediately record medication

administration, including drug, dose, route, time instilled, and date and time administered on MAR. Include initials or signature.• Report any adverse reactions to

patient’s health care provider. Patient’s response sometimes indicates need for additional medical therapy.• Record patient’s medication response

in nurses’ notes and electronic health record (EHR).

SPECIAL CONSIDERATIONS - TEACHING

TEACHING:Teach patient and/or significant other that effects of IV push

medication occur rapidly. Explain reason for giving medication slowly and teach signs of adverse effects.

PEDIATRIC:The therapeutic dosage of IV push medications for infants and

children is often small and difficult to prepare accurately, even with a tuberculin syringe. You need to infuse these medications slowly and in small volumes because of the risk for fluid volume overload.

To maintain pediatric patient safety, carefully follow agency policies when administering medications via IV bolus.

GERENTOLOGICThe renal and metabolic systems do not

function as efficiently because of the aging process.

To reduce the risk for adverse effects of IV push medications, have good drug knowledge about adverse effects and drug interactions.

Older patients may tolerate IV push medications if they are given over longer periods of time.

IMPORTANT INFORMATION TO REMEMBER

While one of the advantages of IV push methods is rapid onset of the medication, remember when giving this medication quickly (e.g., less than 1 minute) there is very little opportunity to stop the injection if an adverse reaction occurs.

Remember, not all medications can be delivered by IV push.The IV bolus is a dangerous method to administer medications

because it allows NO TIME TO CORRECT ERRORS!Make sure when you are administering IV bolus medication, IT

IS THE RIGHT MEDICATION THAT YOU ARE ADMINISTERING!

When the doctor orders IV over 5 minutes, make sure this is given over 5 minutes and not 4 minutes, for example!

DESCRIBE THIS PICTURE – WHY IS THE NURSE LOOKING AT THE TIME CLOCK?

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